Report of Campaign to End Fistula – Pakistan
Definition of obstetric fistula;
An obstetric fistula is an abnormal opening between the vagina and the bladder and/ or the rectum, resulting in uncontrollable leakage of urine and/or faeces. A vesico-vaginal fistula (VVF) occurs between the bladder and the vagina.Aurethro-vaginal fistula (UVF) occurs between the urethra and the vagina. A recto-vaginal fistula (RVF) occurs between the rectum and the vagina • A double fistula occurs between the vagina, the bladder AND the rectum. An iatrogenic fistula occurs inadvertently during a medical procedure (eg Caesarean Section)
Figure 1: Anatomical sites of obstetric fistula.
Figure 2: Anatomical sites of obstetric fistula.
Figure 3: The misery can be seen
Obstetric fistula is a debilitating condition that has left millions of women suffering in solitude caused by prolonged and obstructed labour, it renders survivors incontinent, a condition that often results in stigma and ostracism by communities. Many women are abandoned by their husbands and their families. All but eliminated from the developed world, obstetric fistula continues to affect the poorest of the poor women and girls living in some of the most resource starved regions in the world. Pakistan is one the country situated in that region where due to poor health care services obstetric fistula is a big challenge
In 2001, UNFPA identified obstetric fistula as a neglected reproductive health and human rightsissue —one that is not addressed on a large scale by any other agency. Fistula touches onevery aspect of the women health mandate, including safe motherhood, reproductive rights, adolescentsexual and reproductive health, early marriage and childbearing, gender equity, and the linkbetween access to quality reproductive health services and poverty reduction.
Launched by UNFPA and partners in 2003, the global Campaign to End Fistula is an integralcomponent of UNFPA’s overall strategy to improve maternal health, and includes interventionsto prevent fistula from occurring, to treat women who are affected and to help women who haveundergone treatment return to full and productive lives. The campaign’s ultimategoal is to make fistula as rare in developing countries as it is in the industrialized world. Thetarget for achieving fistula elimination is 2015, in line with the international Conference onPopulation and Development (ICPD) and Millennium Development Goal targets.
Global Fistula Campaign Map
Figure 4; Global Fistula Map
Fistula Project – Pakistan
In Pakistan, End Fistula Campaign started in 2005 in collaboration with UNFPA. Regional fistula centers are providing free treatment services across the country. Details are given below.
1) Koohi Goth Women Hospital Karachi;
Koohi Goth Women’s Hospital (KGWH) has been founded by the endeavors of socially conscious citizens of Karachi. The aim of the hospital is to provide free of cost quality and modern treatment to poor females. At this facility pregnant women are provided with routine maternity as well as emergency care, who would otherwise perish due to lack of adequately trained personnel, medicine and equipment. Mothers who suffer from vesico vaginal fistula suffer from urinary incontinence and hence face abandonment from their husband and families. They reach the hospital from far-flung areas for a simple operation, which is otherwise not available at fee-forservice hospitals. The hospital pledges to treat all patients suffering from various benign or malignant conditions of the female genital tract, irrespective of their caste, color or creed.
Figure 5; Dr.Aziz Abdullah Urologist who repaired highest number of iatrogenic fistula
Figure 6:Koohi Goth Hospital
As prevention of fistula is directly related with the availability of competent midwives PNFWH has started a comprehensive programme to trained midwifery tutors across Pakistan. The selected tutors sty within the premises of koohigoth hospital for six months to complete their training. Following is the record reflecting the achievement of this programme.
2) Sheikh Zaid Women Hospital Larkana.
3) Nister Hospital Multan (Urology Department)
4) a) Sandman Hospital Quetta ((Urology Department)
Urology Department, Sandeman Provincial Hospital Quetta became part of the project previously as a referral center but was later on upgraded to the status of the Regional Center. Dr. Saadat Khan along with his team of the most proficient surgeons namely Dr. Haq Nawaz and Dr. Masha khan have been actively providing support to the project since the year 2007. They have been operating the fistula patients long before the project was launched.
A separate department for Fistula patients was constructed by the UNFPA’s fund and has become the part of the Urology Department.
b) Christian Hospital Quetta
Christian Hospital Quetta has a legacy of providing quality health care of more than 110 years. It was made the Regional Center for Fisula Treatment in the year 2006 with a formal MoU between the Christian Hospital Quetta and the Pakistan National Forum on women’s Health. Christian Hospital Quetta has been providing the support to the project not only by providing treatment to the fistula patients but also providing all sorts of administrative and logistics support to the project worth mentioning are the provisioning of the halls and lecture rooms whenever required for the activities and also accommodating a Center for Rehabilitation and Social Integration of Fistula Patients, within the hospital’s premises.
5) Leady Reading Hospital Peshawar.
Bio of focal person;
Prof.Dr.Nasreen Ruby Faiz
6) Laiquat University Medical Sciences Hyderabad.
Bio of focal person;
Professor Dr. PushpaSrichand
• Best teacher Award Higher Education Commission 2008.
• National culture Award for minority by ministry of Health for minority in 2003.
• Established Fistula Referral centre in 2007 in collaboration with UNFPA.
• Established Fistula Referral centre in 2012 in collaboration with UNFPA 2012
• Works as professor since 1996
• 25 published Research publication in National and International Journals.
• 46 national and International paper presentations
• Performed >500 fistula surgeries.
Figure 12: Prof Pushpa with her team at Hyderabad fistula ward along with successfully repaired fistula patient
Figure 13: Prof, Pushpa&Dr.Nabela along with fistula patient at Hyderabad fistula center
7) Leady Willington Hospital Lahore.
Name: Prof. Dr. YasminRaashid
8) PIMS Islamabad
Name Prof. Ghazala Mahmud
Present Designation Professor, Meritorious of Gynae/Obs
Dean Quaid e Azam Post Graduate Medical College, PIMS, Islamabad
Dean, Faculty of Medicine, Quaid e Azam University, Islamabad.
Profession Gynecologist and Obstetrician
Regional Fistula Conference;(4th-6thMarch 2011, Sheraton Hotel Karachi)
Pakistan National Forum on Women’s Health (PNFWH) and United Nation Funds for People (UNFPA) in collaboration with Society of Obstetricians and Gynecologists of Pakistan (SOGP), Pakistan Medical Association (PMA) and Pakistan Association of Urological Surgeons (PAUS) organized an International gynecological conference on Genital Tract Fistula. Following were the key international fistula surgeons who had participated & operated selected fistula cases.
Figure 17; inaugural session of International Fistula Conference
1. KeesWaaldijk, Nigeria President International Society of Obstetrical Fistula Surgeons (ISOF)
2. Stephan Vanderputte, Belgium
3. Lauri J. Romanzi, USA
4. Kathyms Grant, USA
5. SayebaAkhter, Bangladesh
6. KunduYangzom, Nepal
7. MuluMeletaBedane, Ethiopia
8. LoveluckMwasha, Tanzania
9. Nadine Devooght, Belgium
10. Gadelkarim R.E. Nasar, Egypt
Achievements Fistula Project Pakistan:
a) Patients treated
b) Capacity building;;(Doctors trained)
c) Nurses & midwives trained;
437 nurses & midwives being trained on fistula prevention and Post-operative care
• Four centre (Karachi, Quetta, Hyderabad and Multan
• 100 patients rehabilitated in 2012
e) Raising Awareness on maternal health & fistula prevention;
In Pakistan, UNFPA is partnering with selected civil society organizations and women’s groups to highlight harmful cultural practices (including child marriage) through media, advocacy and dialogue, as well as to support initiatives aimed at promoting the Women’s Protection Bill.
In the local circumstances PNFWH in collaboration with UNFPA produce a TV play -“JEOWN GEE MAY SAR UTHA KAY” for promotion of maternal health issues in Pakistan for general public.
Women Parliamentarian caucus at Parliament House Islamabad
f) Out Reach fistula Surgical Camps;
It’s one of our most important componentsof fistula project to treat patients at far flung areas. PNFWH plan such camps at every province annually.
Figure 21; Fistula surgical camp Their Mir Wah
International Fistula Working Group – Meetings;
Pakistan team participated in all three IFWG meeting to review and plan the strategy at regional level. The meetings were held at the following places.
1st Meeting NarobiKenya
2nd Meeting Dakar, Senegal
3rd Meeting Dahkha Bangladesh
Challenges – Iatrogenic fistula;
• 37% of cases reported cases specially from southern Punjab
• Technical Assistance Surgeries/Technical skills of new surgeons?????
• Issue of Competence
• Issue of Negligence
• Issue of training
• Issue of Regulation of PMDC, CPSP………………….
Figure 22; Brain storming on iatrogenic fistula – Quetta
• Shortage of Fistula Surgeons and retirements of Focal Persons/leading fistula surgeons at Peshawar & Lahore centre created shortfall in numbers of fistula patients treated
• Prevention of OF, Cultural & Social, obstacles Shortage of SBA.
• Capacity Building – trainees with master trainers
• Non priorities of government facing difficulties in integration fistula into safe motherhood and RH strategies
• Increasing burden of Iatrogenic Fistula
• Training of doctors, Nurses & Midwives
• Training Private consultants on fistula repair
• Rehabilitation center for Fistula patients (Skill, Education) needed at all regional centers.
• Jobs for non- repairable patients
• Local fund generation including fund raising campaigns
• Liaison with Zakat and usher committees for fistula funds allocation on yearly bases
Moving Forward – Future Plans
Obstetric fistulas can be prevented by a functioning health system, including access to CEmONC facilities, a good referral system and trained, skilled attendants at delivery. This all can be done only by producing well trained, competent midwives across the country.Since its inception, a key focus of the Campaign to End Fistula has been advocacy and political support for the integration of obstetric fistula into national sexual and reproductive health (SRH) and maternal and newborn health (MNH) policies and plans, this task is still a big challenge for Pakistan. In future this would be the main goal of campaign to bring fistula into the main stream of reproductive health. Effective and collaborative partnership is the cornerstone of the campaign’s efforts at all levels. UNFPA serves as the Secretariat of the International Obstetric Fistula Working Group (IOFWG), which now includes more than 25 global and regional partner agencies including Pakistan to provide technical inputs for eradication of obstetric fistula.
Obstetric fistula is both preventable and treatable. While there have been increasing efforts to eradicate the condition, there is still much to do. This will involve obtaining political will to ensure universal access to skilled birth attendance and emergency obstetric care for all women; raising awareness relentlessly about the condition, and unifying the fistula community to improve outcomes for fistula sufferers. Eradication of obstetric fistula has already been achieved in many low-resource countries, proving that it is attainable. This eradication will not only alleviate the misery of millions of women and young girls, it will also help to secure safe motherhood for all women.
“The Campaign to End Fistula has achieved much in terms of awareness building and service development and has been a catalyst to mobilize countries towards addressing fistula prevention, treatment and care.” However, there is much more to do — as the ambitious goal of fistula elimination in the regions most affected has not yet been achieved.
Story of GulBano
Figure 23; GulBano fistula patient – working as fistula ambassador
GulBano, resident of KohadastKhuzdar in Baluchistan, was put into marriage when she was not even 13. She became pregnant almost immediately, and spent the entire pregnancy at her husband’s native village where no antenatal care was available. According to GulBano, it didn’t matter because the antenatal period was uneventful anyway. She enjoyed her pregnancy after the initial few weeks of nausea and vomiting. The onset of labour was also normal at the estimated time. The local TBA (DAI) saw her at home and assured the family that she would have a normal vaginal delivery. She was in labour for two days, and the contractions were strong which made her feel exhausted and drowsy. At the end of these long two days and two nights, she delivered a dead fetus. She also had injury in perinanal area and developed fever. The TBA gave her some antibiotic to which she responded and become a febrile.
She was well for the first week, but on the eighth day she realized that she was passing urine and feces from the vagina. She, her husband and the local TBA did not have any a clue what was going on or what the nature of her problem was. She stopped venturing out of her mud house as she was dirty, smelling foul and nobody in the entire village wanted to talk to her. She herself felt that life had no future for her. Despite the support of her husband, which is a rarity in such cases, she seriously thought about committing suicide.
She had spent a miserable period of two years with the condition when her younger sister QusBano got married. Luckily, her husband knew of a center in Karachi where women VVF and RVF were being treated for free. He convinced the family to approach the center and so they all agreed to travel to Karachi to seek help.
The long journey from the village took them two days through the mountains to reach the highway from where they took a wagon tide to reach Khuzdar, which is a small town some six hours away on the way to Quetta. From Khuzdar they took an eight-hour bus ride to reach the hospital at Karachi.
This was the first time GulBano had ever traveled in a motorized vehicle. Not just that, it was her first experience of what a carpeted tarmac road was. She and her sister had never seen bulbs, television sets, hospitals, doctors, nurses, buildings … the list was long!
She was week, anemic and needed treatment just to be fit enough to be operated upon. It was not before two months that surgery was finally scheduled. Initially, a colostomy was performed. After six weeks, a successful operation was performed to close the RVF, ad another six weeks later, the VVF was also repaired. After the RVF and the VVF were plugged, the colostomy was reversed.
GulBano was discharged a week before Eid, the traditional festival of Muslims across the world. By then she had spent seven months at the Koohi Goth Women’s Hospital in Karachi which is the Fistula Regional Center. A party was organized to celebrate her recovery, and she insisted on having a photograph with the whole team of doctors, nurses, paramedical staff, even the cooks and other staff with whom she had stayed for so long. The staff gave her new clothes as a mark of the new filth-free life which was embarking on after the recovery. She was told that she could even become pregnant; but that she would never have a normal delivery and that she should come back to the center where Caesarean Section facility was available.
Today, GulBano is happy to have regained her lost status in the eyes of her family, community, society and, above all, in her own eyes. She has already brought to the Koohi Goth Hospital in Karachi a couple of women who were also suffering from the same ailment. She is a mobile ambassador of goodwill who spreads the word around where it needs to be spread.